I. Personal Information How did you find out about us? Address
Hobbies
II. General Information Do you Have any Allergies (Penicillin, bee stings, food, etc?)
Do you have any food concerns? Are there foods you don’t like to eat? Meals at Camp Zen Commando are primarily plant and whole food-based.
Do you have any physical conditions we should be made aware of in case of emergency? The activities at Camp Zen Commando are low-impact and all stress is self-induced.
Are you okay with living in a shared space? Our guesthouse has a kitchen, bathroom, river patio, and a large space for sleeping and storing personal items. We aim to ensure the utmost respect is given to our guests
What are your expectations of the course? What do you want to gain from it?
III. Medical Information Please select any physical health conditions you are experiencing right now or have experienced in the past
Please list any other physical health condition not listed above.
Please tell us, in your own words, about your current and past health situation. What conditions play a part in your life? How long has it been that way? Have you had serious health issues in the past?
Have you ever had major surgery of any kind? If yes, what kind of surgery and when did it take place?
IV. PSYCHOLOGICAL / PSYCHIATRIC INFORMATION Please select any conditions you are experiencing right now or have experienced in the past
Please list any other psychological/psychiatric information not listed above.
Have you ever been hospitalized or received treatment/therapy for one of the above conditions?
Are you currently taking or have you ever been prescribed any medications for these condition(s)?
Is there any history in your immediate family of the psychological/psychiatric conditions mentioned above? If yes, Please provide more information. What conditions effects/effected which family members.
V. Trauma Have you ever experienced a serious physical trauma? If yes please tell us more about this:
Women: Did you have a difficult birth? (This might seem a strange question but people often relive a (traumatic) birth during an Ayahuasca ceremony.) If yes please tell us about your birth.
Are you aware of any sexual, physical, or emotional abuse in your past? If yes, can you tell us more about this?
VI. Addiction and Drug Use How many alcoholic drinks do you normally consume each week?
Have you ever been diagnosed, treated, or self-identified as an alcoholic?
Have you ever used street- or recreational drugs (including Marijuana)?
Have you ever been diagnosed with, or treated for a drug or addiction?
Please list any other addictions you have had or currently have.
VII. Medication Are you allergic to any medication?
If you answered "yes" to the above, please indication type of medication
Are you currently taking or have you recently stopped taking (within the last month) antidepressants?
List any medications, to include antidepressants that you are currently taking. If none, write "NONE"
Are you currently taking or have you recently stopped taking (within the past month) any natural supplements, herbal medicines, or vitamins (including St. John wort, 5-HTP, Kava etc.)?
VIII. Emergency Contact Please ensure you submit reliable contact information. We recommend you use the mobile communication device application "Whatsapp" for the communication median and your designated Emergency POC is also using that median.
IX. Terms and Agreements
Liability Release and Assumption of Risk
In consideration of being allowed to participate in any way in Zen Commando programs, its related events and/or activities, I fully understand, acknowledge, appreciate, and agree that:
1. The risk of injury from the activities involved in this retreat, course, or program may be significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, I hereby assert that I knowingly assume all of the inherent risks of the activity and take full responsibility for any and all damages, liabilities, losses, or expenses that I incur as a result of participation.
3. I certify I am over 18 years of age and willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the staff immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Zen Commando, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER, ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law.
5. I grant permission to Zen Commando to use my photograph and/or any other record of my participation for any legitimate purpose. I understand that any and all photographs, motion pictures, recordings, and/or likenesses of me captured during Zen Commando Programming by Zen Commando become the sole property of Zen Commando. I grant the right, permission, and authority to Zen Commando to use my name and any such photographs, motion pictures, recordings, and/or likenesses for any legitimate purpose, including but not limited to promoting advertising, and marketing activities.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY AGREEING TO IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT
I have read and understand the liability release. I release Todd Opalski, Zen Commando, and any staff member of any liability I may incur.
"The Camp Zen Commando Agreement"
I agree to attend and participate as best I can in all activities while at Camp Zen Commando. I agree to arrive on time, with a positive attitude, a sense of good humor, an open mind, and be ready to learn. I understand that I must do my best to cooperate with everyone in the course (instructors, staff, guests, students) and that this event is not a vacation.
All rules and regulations of Camp Zen Commando must be adhered to:
1. We are a substance and chemical-free environment that emphasizes a clean, respectful, and healthy lifestyle.
2. If I am uncomfortable with any physical aspect of the training (e.g., fitness exercises, hikes, yoga postures, survival situations, breathing exercises, etc. ) I will attend, listen, learn but may choose to not participate for my own reason.
3. A major part of being at Camp Zen Commando is getting along with others and being open to new ideas and methods. I promise to be respectful of others' space, thoughts, actions, and viewpoints and not judge or discriminate.
I understand participation is at my own risk and I am in good health and able to perform all tasks which may be asked of me while at Camp Zen Commando. Again, I understand that my physical participation is my responsibility and I am comfortable modifying any exercise or movement as needed and will communicate clearly and timely any issues I may have with the physical aspects of the course. I release my image and video for use by Zen Commando for marketing and social media purposes or I will ensure I am not in the photos or videos.
I have read, understand, and will comply with the Camp Zen Commando Agreement
I testify I am at least 18 years of age
I will discontinue all use of alcohol, marijuana, recreational/street drugs and non-prescribed pharmaceuticals at least two weeks prior to coming to Camp Zen Commando. I understand that these are strongly contraindicated with Ayahuasca and can be very dangerous and potentially fatal when combined.
I have completed this questionnaire myself, have answered truthfully, and understand that withholding or misrepresenting any information could result in serious complications when drinking Ayahuasca.
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